A prison where a heroin addict died after going "cold turkey" ran a disorganised medical system, according to an inquest jury.
The jury at Sutton Coldfield town hall recorded a narrative verdict at the conclusion of the inquest into the death of Darren Davies.
The 23-year-old died at Winson Green Prison in Birmingham in March 2001.
The jury said he died of natural causes but added the medical system was disorganised due to lack of resources.
A narrative verdict is one in which a coroner simply records the circumstances surrounding the death.
Difficult to assess
Several nurses had been out to see Davies prior to his death.
But the jury ruled that because of the disorganised medical system it was difficult for staff to properly assess his condition.
A previous inquest into Davies' death recorded a verdict of accidental death. The High Court ordered the second inquest after an appeal made by his mother.
Mr Davies was found dead by his cellmate. He died of a heart attack caused by dehydration due to vomiting.
He had been jailed for stealing coffee and toothpaste and decided to go "cold turkey" to kick his drug habit.
Mr Collins told the inquest how over the four days Davies became progressively weaker and eventually did not leave his cell.
He said something should have been done when Davies was seen an hour before his death.
They said phone calls were made to Winson Green requesting help because they knew of his drug problems.
The inquest heard the prison did have people prepared to listen and that someone always came when the buzzer was rung.